Credentialer/medical malpractice insurance collaboration

ABSTRACT

An inventive process is disclosed for linking a medical malpractice insurance application with a credentialing questionnaire. The insurance information is automatically transferred from the insurance application to a credentialing questionnaire, and this information is then used to generate a credentialing application.

I. BACKGROUND

A. Field of Invention

This application is a continuation application of U.S. Ser. No. 11/042,683, filed Jan. 25, 2005, which is a continuation of U.S. Ser. No. 09/339,479, filed Jun. 24, 1999, which is now U.S. Pat. No. 6,862,571; this application is also a continuation application of U.S. Ser. No. 12/133,467, filed Jun. 5, 2008, which is a divisional of U.S. Ser. No. 10/067,181, filed Feb. 4, 2002, which is now U.S. Pat. No. 7,469,214, which is a continuation-in-part of U.S. Ser. No. 09/339,479, filed Jun. 24, 1999, which is now U.S. Pat. No. 6,862,571, all of which are incorporated herein by reference. This invention pertains to the art of processes for linking a medical malpractice insurance application with a credentialing questionnaire.

B. Description of the Related Art

It is well known that regulatory agencies in the United States require health professionals to have their credentials verified every two years. Verification is a time consuming process that typically includes the assembly of various documents, including proof of the physician's license, a valid Drug Enforcement Agency certificate, proof of completion of medical school, proof of board certification, proof of appropriate work history, etc. Thus, the verification process often takes many days and sometimes weeks to complete. Unfortunately, this time consuming process is the only known way that the regulatory agencies can ensure the public that it is receiving care from a qualified medical professional.

It is also well known that the National Committee for Quality Assurance (NCQA) sets the standard for credentialing in managed care organizations. Defined as “the process by which a managed care organization authorizes, contracts, or employs, practitioners, who are licensed to practice independently, to provide services to its members,” credentialing simply means making sure that a practitioner is qualified to render care to patients.

Although there is likely to be some variation on the specific criteria used, the basic elements required in establishing proper credentialing information for a physician are likely to include the following: a valid and current license, clinical privileges in a hospital, valid Drug Enforcement Agency (DEA) or Controlled Dangerous Substance certificate (CDS), appropriate education and training (i.e. graduation from an approved medical school and completion of an appropriate residency or specialty program), board certification, appropriate work history, malpractice insurance, and a history of any liability claims. Managed care organizations also credential nonphysician practitioners, such as dentists, chiropractors, and podiatrists. The primary differences between physician and non-physician practitioners for purposes of credentialing, lie in the requirements, and therefore, in the verification of select data. For example, chiropractors are not board certified and do not require DEA or CDS certificates.

Credentialing is a necessary and critical step in securing qualified practitioners to render and manage the care of managed care organization subscribers or members. The managed care organizations oftentimes delegate certain activities in the credentialing process. A Credentials Verification Organization (CVO), which may be certified by NCQA, will verify a practitioner's credentials for a set price. Contracting with a NCQA-certified CVO exempts the hospital, healthcare entity, or managed care organization from the due diligence oversight requirements, specified by NCQA and the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), for all the verification services. By contracting out the necessary credentialing to a NCQA-certified CVO, the managed care organizations have met their due diligence requirements.

CompHealth, a licensed CVO in the United States, has developed a new web-based credentialing service, moving as much of the process online as possible. One of the keys to the credentialing service is an Internet application called Apply.net. Medical professionals can use the Apply.net application to submit their information to CompHealth via the Internet. However, there is currently in the art no known connection between the credentialing services, the credentialing information, and the insurance industry.

The Federal government has attempted to alleviate some of the problems of credential sharing among separate government entities. The Federal Credentialing

Program was created to attempt to electronically link credentialing databases among the federal agencies and departments. However, this credentialing information sharing is limited to the federal government and does not involve the insurance industry.

The present invention provides a process for quickly and efficiently linking credentialing information with a medical malpractice insurance policy. Difficulties inherent in the related art are therefore overcome in a way that is simple and efficient while providing better and more advantageous results.

II. SUMMARY

In accordance with one aspect of the present invention, a method for ensuring current information for insurance underwriting when credentialing information has been obtained from a healthcare provider includes the steps of obtaining a release of the associated credentialing information from the associated healthcare provider, updating the associated credentialing information with new information, the new information being collected by an associated insurance entity, being at least one of the group comprising: no new information, medical incident, the medical incident occurring after compiling of the associated credentialing information, likely to become a claim for damages against the healthcare provider, claim for damages arising after compiling of the associated credentialing information, lawsuit arising after compiling of the associated credentialing information, and change to healthcare provider's practice profile, and evaluating the new information.

In accordance with another aspect of the present invention a method for underwriting insurance in between recredentialing periods includes the steps of obtaining a release of associated credentialing information from an associated healthcare provider, reviewing the associated credentialing information, and updating the associated credentialing information.

In accordance with still another aspect of the present invention, the method includes the step of updating the associated credentialing information updating the associated credentialing information with new information, the new information being collected by an associated insurance entity, being at least one of the group comprising: no new information, medical incident, the medical incident occurring after compiling of the associated credentialing information, likely to become a claim for damages against the healthcare provider, claim for damages arising after compiling of the associated credentialing information, lawsuit arising after compiling of the associated credentialing information, and change to healthcare provider's practice profile.

In accordance with yet another aspect of the present invention, the method includes the steps of evaluating the new information, generating an insurance premium quote, and generating a medical malpractice insurance policy based on the new information.

In accordance with another aspect of the present invention, the method includes the steps of obtaining a release of associated credentialing information from an associated healthcare provider, the release being obtained via a global computer network and reviewing the associated credentialing information, the information being view via the global computer network.

In accordance with still another aspect of the present invention, an apparatus for insurance underwriting between recredentialing periods includes means for obtaining a release of associated credentialing information from an associated healthcare provider, means for reviewing the associated credentialing information, and means for updating the associated credentialing information.

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In accordance with yet another aspect of the present invention, the apparatus includes means for updating the associated credentialing information updating the associated credentialing information with new information, the new information being collected by an associated insurance entity, being at least one of the group comprising: no new information, medical incident, the medical incident occurring after compiling of the associated credentialing information, likely to become a claim for damages against the healthcare provider, claim for damages arising after compiling of the associated credentialing information, lawsuit arising after compiling of the associated credentialing information, and change to healthcare provider's practice profile, means for evaluating the new information, means for generating an insurance premium quote, and means for generating a medical malpractice insurance policy based on the new information.

In accordance with still another aspect of the present invention, the apparatus includes means for obtaining a release of associated credentialing information from an associated healthcare provider, the release being obtained via a global computer network and means for reviewing the associated credentialing information, the information being view via the global computer network.

Still other benefits and advantages of the invention will become apparent to those skilled in the art to which it pertains upon a reading and understanding of the following detailed specification.

III. DESCRIPTION OF SEVERAL EMBODIMENTS

The inventive process is designed to link credentialing information with a medical malpractice insurance application. The credentialing information, which the regulatory agencies require of health professionals, can be compiled for each physician by a credentials verification organization (CVO). The credentialing information, however, can be gathered by any entity licensed to do so. The CVO typically obtains and/or verifies required information about each physician, including, a valid and current license, clinical privileges at a hospital, valid DEA or CDS certificates, appropriate education and training (i.e., graduation from an approved medical school and completion of an appropriate residency or specialty program), board certification, appropriate work history, malpractice insurance, and a history of liability claims. This information is used by healthcare entities to ensure the public that it is receiving adequate care from a qualified medical professional. What is to be especially noted is that the information gathered by the CVO is virtually identical to the information required to underwrite a medical malpractice insurance policy.

The inventive process begins by having the CVO include means for obtaining the physician's permission for release of the credentialing information to the medical malpractice insurance participant. This means for obtaining the physician's permission could be in the form of a question added to the questionnaire, requesting the physician's permission. An example of what the question might be is, “May we release this information for the purpose of obtaining competitive malpractice insurance quotes for you?” The means for obtaining permission could also include a statement above the signature line stating that by signing the questionnaire the doctor is giving the CVO permission to release the information to the medical malpractice insurance participant. All of the credentialing questionnaires in which such permission is granted are then automatically forwarded by the CVO to the medical malpractice insurance participant. What is meant by the term “medical malpractice insurance participant” is any one, or more, of the following: insurance companies, brokers, agents, third party administrators, risk bearers, claims managers, risk managers, insurance marketers, and the like.

Using the credentialing information, at least one insurance premium quote is generated for the medical malpractice insurance policy. The medical malpractice insurance participant can provide multiple quotes from various insurance companies to the physician. The insurance participant then contacts the physician with the premium quotes and policy terms and conditions. By “quote” it is meant either a non-binding or binding quote of the cost of the insurance policy premium.

If the physician orders the medical malpractice insurance, the credentialing information is transferred from the credentialing questionnaire to a medical malpractice insurance application. An application for medical malpractice insurance is then generated by a computer for the physician.

The insurance participant then delivers the completed application to the physician for the physician's review and approval.

Once the medical malpractice insurance policy has been approved by the physician, a two year policy is generated by the insurance participant. This two year policy coincides with the required re-credentialing procedure for the physician. The physician will no longer be required to fill out a new application for medical malpractice insurance each time the medical malpractice policy comes up for renewal. Each time the re-credentialing is done, which, in the preferred embodiment, occurs every two years, the updated credentialing information can then be sent again to the insurance participant, and the medical malpractice insurance policy can be renewed with expediency and efficiency.

The two year medical malpractice insurance policy is a preferred embodiment of the invention, and is not intended to limit the invention in any way. The current inventive process also encompasses any length of policy term that coincides with the re-credentialing process. For example, if the re-credentialing occurs every three years, instead of every two years, a three year medical malpractice insurance policy can be issued.

Also, the information on the medical malpractice insurance application, since it is almost identical to the credentialing information, can be transferred back to a credentialing questionnaire for any subsequent health organizations that require credentialing of the subject physician. The medical malpractice insurance participant can transfer this information, and send copies of the credentialing questionnaires to the various health organizations, thereby saving the physician a great deal of time and effort. The physician will no longer be required to fill out multiple credentialing questionnaires for multiple health organizations. In the past, a physician had to fill out a credentialing questionnaire for each and every health organization from which they desired approval. With the inventive process, the physician need only fill out one credentialing questionnaire, and from that, the process transfers the information to a medical malpractice insurance application. From the insurance application, the credentialing information can be transferred to multiple questionnaires to send out to multiple health organizations. All that the physician needs to do is to contact the medical malpractice insurance participant and request that the insurance participant complete a credentialing application for whichever health organization the physician wishes. The medical malpractice insurance participant can then transfer the information from the insurance application to the credentialing questionnaire and provide the completed questionnaire to the physician. The physician then reviews the credentialing questionnaire, signs it, and submits it to the credentialing entity, or health organization. The inventive process encompasses all of the subsequent applications and questionnaires that the physician would need for any subsequent health organizations that require the credentialing information.

If a physician has already obtained medical malpractice insurance coverage, the medical malpractice insurance participant will have all, or most, of the information necessary for the credentialing process. This invention also encompasses the initial step of the process being the medical malpractice participant transferring the information from the medical malpractice insurance application to the credentialing questionnaire. In this manner, the credentialing process can be efficiently and quickly completed even after the physician has a medical malpractice insurance policy.

In either of the situations where the information is going from the insurance application to the credentialing questionnaire, or vice versa, it is possible that some of the questions will not match up. If one of the questions on either the credentialing questionnaire or the insurance application is left blank due to the questions not matching up, these questions will be highlighted, and when the physician receives the application or questionnaire, the physician will fill in the highlighted blank spaces.

In the preferred embodiment, the inventive process occurs automatically via electronic transmission and computer data manipulation. The required computer hardware, and the necessary computer code, would be obvious to one skilled in the computer art.

However, this invention is not limited to the preferred embodiment, and can be accomplished without the use of computers or electronic means. The methods of transferring information manually, or by way of a hybrid combination of manual and electronic transference, are both encompassed by this invention. In the manual, or hybrid of manual and electronic, transference embodiments, the steps taken to link the insurance application with the credentialing information are identical to the steps taken in the preferred embodiment, and those steps are incorporated herein by reference.

The present invention is also not limited to the medical malpractice field, but includes the entire range of insurance participants. The present invention can be used to link any information database, not created for insurance purposes, to any type of insurance application. The only information databases not encompassed within this invention would be databases created for the purpose of filling out an insurance application, or for the purpose of obtaining any type of insurance. An example of the type of information database not encompassed within this invention would be an Internet insurance application form. However, any other information database, not created for insurance purposes, can be linked by this inventive process to an insurance application. The means by which this information is linked with the insurance application is identical to the process described in the medical malpractice insurance process, and the steps of the process are incorporated herein by reference. However, when linking the information to other forms of insurance, further questions may need to be added in order to gather further, necessary information. An example of some further questions, necessary for life insurance, would be whether someone is a smoker or a nonsmoker.

The types of insurance applications that can be linked can include, but are not limited to, the following: life insurance, automobile insurance, medical malpractice insurance, legal malpractice insurance, professional liability insurance, health insurance, disability insurance, renter's insurance, homeowner's insurance, flood insurance, fire insurance, hurricane insurance, and earthquake insurance, or any other line of insurance.

It is to be noted that the invention encompasses the idea that the credentialing organization, the healthcare entity, the insurance participant, etc. can be one entity or separate entities. For example, a hospital that does its own credentialing and provides insurance for its physicians is encompassed within this invention.

In another embodiment of this invention, there is no need for a credentialing questionnaire to be provided. The CVO should have all the data necessary for filling out an insurance application, and all that would be needed would be the physician's permission for use of the information. In this embodiment, the initial step of the process would be transferring the credentialing information from the CVO directly into either an insurance application or an insurance policy.

The invention also encompasses the use of electronic transmission of the information to the physician for the physician's approval. The physician could then send approval for the insurance policy back to the insurance participant. Under this method of the invention, no signature is required by the physician, only the physician's approval of the insurance policy.

In underwriting insurance, the insurers need accurate and up to date information about all aspects of a healthcare provider's practice in order to properly underwrite the provider, and to properly evaluate the risk of exposure or loss that the provider poses to the insurer. Once the credentialing process is completed, it is generally two years before the process is repeated. In this embodiment of the invention, the credentialing process is integrated in between the credentialing and recredentialing time periods.

In this embodiment, the insurer or credentialing entity secure a release from the healthcare provider so that the credentialing information can be reviewed. If a healthcare provider changes some aspect of his practice, or desires a new insurance policy for any reason, the insurance company needs to have the most up to date information possible. If the provider has submitted credentialing information eight months ago, then any information between that time and two years later will be unavailable to the insurer. The release of information can be on the original credentialing package, an insurance application, a separate form, or any other means chosen using sound business judgment.

In order to effectuate the collaboration between the credentialing process and the issuance of insurance, the insurer will need additional information, such as the disclosure of all known medical incidents likely to become a claim for money or damages against the provider which had not been disclosed in the most recent credentialing or recredentialing process, disclosure of any or all actual claims for money or damages, or lawsuits against the provider, involving the provider subsequent to the completion of the most recent credentialing or recredentialing process, or disclosure or any changes to the provider's practice profile since the most recent credentialing or recredentialing process. Changes to the practice profile generally include changes that would alter risk exposure (i.e. change in practice location, addition or deletion of procedures performed by the provider, loss or addition of physicians, loss or addition of ancillary personnel, or change in the number of hours practiced by provider.)

It is to be understood that the listed additional information is not intended to limit the invention in any manner, but is only delineated to be a representative sample of the possible information. Any additional information can be used, as long as chosen using sound business judgment.

In another embodiment of this invention, the entire process can take place via a global computer network.

The invention has been described with reference to preferred embodiments. Obviously, modifications and alterations will occur to others upon a reading and understanding of this specification. It is intended to include all such modifications and alternations in so far as they come within the scope of the appended claims or the equivalents thereof.

Having thus described the invention, it is now claimed: 

1. A process of linking a medical malpractice insurance application with a credentialing questionnaire, the process comprising the steps of: obtaining a release of previously submitted insurance information, wherein the insurance information was previously submitted to an associated insurance entity; electronically transferring at least a portion of the information from the medical malpractice insurance application to the credentialing questionnaire; and, electronically forwarding the credentialing questionnaire to an associated healthcare provider for review and approval.
 2. The process of claim 1, wherein the process further comprises the steps of: providing at least one blank space on the questionnaire where information from the insurance policy does not match with at least one question on the questionnaire; and, requesting information from the healthcare provider to fill in the at least one blank space.
 3. The process of claim 1, wherein the process further comprises the step of: forwarding the completed questionnaire to an associated credentialing entity.
 4. The process of claim 1, wherein the process further comprises the steps of: inserting means for obtaining the healthcare provider's permission, for release of the insurance information to a credentialing entity, into the insurance application; and, electronically forwarding all of the insurance applications with an affirmative response to the credentialing entity.
 5. The process of claim 4, wherein the process comprises the steps of: generating a second credentialing application; electronically transferring the insurance information from the insurance application to the second credentialing application; and, sending the second credentialing application to another health organization to which the healthcare provider must provide credentialing.
 6. The process of claim 5, wherein the process further comprises the step of: repeating the preceding three steps of claim
 5. 7. The process of claim 1, wherein the process further comprises the step of: verifying the information.
 8. A non-transitory computer readable medium including instructions for linking a medical malpractice insurance application with a credentialing questionnaire, the computer readable medium comprising the steps of: transferring at least of portion of information from the medical malpractice insurance application to the credentialing questionnaire; and, forwarding the credentialing questionnaire to an associated healthcare provider for review and approval.
 9. The computer readable medium of claim 8, further comprising the steps of: providing at least one blank space on the questionnaire where information from the insurance policy does not match with at least one question on the questionnaire; and, requesting information from the healthcare provider to fill in the at least one blank space.
 10. The computer readable medium of claim 8, further comprising the steps of: forwarding the completed questionnaire to an associated credentialing entity.
 11. The computer readable medium of claim 8, wherein the process further comprises the steps of: inserting means for obtaining the healthcare provider's permission, for release of the insurance information to a credentialing entity, into the insurance application; and, forwarding all of the insurance applications with an affirmative response to the credentialing entity.
 12. The computer readable medium of claim 11, wherein the process comprises the steps of: generating a second credentialing application; transferring the insurance information from the insurance application to the second credentialing application; and, sending the second credentialing application to another health organization to which the healthcare provider must provide credentialing.
 13. The computer readable medium of claim 2, wherein the process further comprises the step of: repeating the preceding three steps of claim
 12. 14. The computer readable medium of claim 8, wherein the process further comprises the step of: verifying the information. 